Racial Disparities in Functional Impairment at the Very End Stages of Life

Racial disparities in life expectancy and mortality in the
United States are longstanding and well-documented. In fact, for as long as researchers
have collected data on mortality in the United States, studies show that White
Americans have consistently enjoyed longer and healthier lives than Black
Americans, with the most recent estimates by the CDC continuing to show a gap
of about 3.5 years.

Yet despite these persistent differences in longevity, and counter to expectations, researchers have also found that racial differences in health tend to narrow in mid- to later-life. For example, Black adults generally experience higher rates of functional impairment (such as difficulty walking, climbing stairs, or lifting heavy objects) than their White peers, except at much older ages. At these older ages, some researchers have instead found that rates of impairment become similar—or converge—among both groups[1], shown in Figure 1.

Other studies have found that Black-White rates in functional impairment stop widening at older ages, resulting in a constant or persistent—rather than growing—disparity in health[2], shown in Figure 2.

One likely explanation for these inconsistent findings is
that higher mortality rates among young and middle-aged Black Americans may
result in a selective process where only the lucky few and most advantaged survive
to the oldest ages. This may inadvertently distort statistical analyses such
that it only appears that Black-White disparities narrow at older ages. Alternatively,
this phenomenon may truly reflect a closing gap in racial disparities in health
because the process of aging may universally deteriorate health for all groups.
Additionally, federal programs such as Social Security and Medicare become widely
accessible to all older adults, especially over the age 65, which may further
reduce Black-White inequalities in resources and subsequent health outcomes. Understanding
the true mechanisms underlying this process of diverging or converging health
outcomes among Blacks and Whites has important implications for how governments
and institutions estimate healthcare costs and allocate health services, as
well as determining when in a person’s life interventions are needed the most.

Therefore, to address these conflicting findings, our study examined differences
in functional impairment rates among a large North Carolina sample of Black and
White, older adults during the vulnerable years leading up to the moment of
death. The advantage of this approach is that it enabled us to set up a more
direct comparison of Black-White differences in health in individual lives, while
overcoming some methodological biases that may occur from higher rates of mortality
among younger Black adults. Using this alternate approach, our results
indicated that functional impairment rates among older Black adults increase at
a faster pace than their White peers within the 2 years immediately preceding
death. This Black-White divergence would not have been clearly visible had we
adopted the standard approach, which typically uses an arbitrary age to set
health comparisons. Additionally, our models also showed that financial resources
necessary to address arising health needs, such as income, are especially
important in reducing racial differences in impairment rates.

Overall, our study demonstrates the importance of exploring
new methodological approaches when examining racial disparities in health. By shifting
our focus from chronological age, our results highlight the individualized
process of aging and the ongoing impact of inequality at the last stage of life.
It is important to emphasize that our findings suggest that this inequality is
not inevitable, however. Our analyses also indicated that resources such as
income and supplemental health insurance are important for maintaining greater
functional independence at older ages and can help to reduce the Black-White
disparity. Accordingly, policymakers must strive to make greater and more
equitable investments in health-related resources for Black Americans and other
disadvantaged groups, even at the very end of life.

Stella Min earned her Ph.D. in Sociology from FSU in 2018.

Miles Taylor is an Associate Professor in the Department of Sociology.